Manatee Springs Rehabilitation And Nursing Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from neglect by not responding appropriately to an exit door alarm and not providing adequate supervision to prevent elopement. The resident had diagnoses including dementia, psychotic disorder with hallucinations, depression, delusional disorder, falls, muscle weakness, and lack of coordination. A recent MDS showed a BIMS score of 6, indicating severe cognitive impairment, and progress notes documented wandering, impulsivity, agitation, difficulty with redirection, and concern for safety. The resident had been assessed as at risk for elopement, with an elopement risk score of 19 on admission (≥12 indicating risk) and a subsequent score of 10, and the care plan identified elopement risk related to cognitive impairment with interventions such as notifying other departments of elopement risk and using verbal cues and distraction techniques. On the night of the incident, the resident was last seen by the assigned CNA around 2:30 a.m. in bed asleep. Shortly thereafter, an emergency stairwell exit door alarm by the therapy department sounded. Video footage later reviewed by the Director of Plant Operations showed the resident, without a walker or wheelchair, walking down the therapy hallway holding the railing, leaning on the stairwell door at approximately 2:32 a.m., triggering the alarm and the audible message “Exit now, exit now,” and then opening and closing the door. The resident then descended two flights of stairs and exited the building through another alarmed door to the outside, all unwitnessed by staff. The stairwell and exterior areas had no cameras, and no staff were observed responding to the alarm during at least 20 minutes of reviewed footage. Multiple staff heard or were informed of the alarm but did not initiate the facility’s elopement procedures. The supervising LPN on duty, who was on the second floor when the alarm first sounded, attempted to silence the alarm but could not recall the code and assumed the alarm was malfunctioning. She contacted maintenance for assistance and then returned to other tasks on the first floor without initiating a search, checking outside, or calling a code for a head count. The assigned CNA was on break when the alarm sounded, received a call from the supervisor about the alarm, and believed it was another malfunction similar to a prior event; he did not check on his residents when he returned from break and recalled the alarm still sounding. The LPN assigned to the resident heard an unfamiliar alarm but did not recognize its source, did not immediately verify resident whereabouts, and reported not having been trained on elopement drills or the sound of the door alarms. Other staff on the first floor either did not hear the alarm or were told by the supervisor that it was a malfunction. During this time, the resident left the facility, walked through the parking lot, crossed a four-lane road, and entered a neighborhood where he fell, sustaining a left forehead laceration and left elbow skin tear, and was eventually found outside, wet and shivering in the rain, by local law enforcement and transported to the hospital. The facility did not become aware of the resident’s absence until notified by law enforcement, and the resident had been missing for approximately two hours without staff knowledge, leading surveyors to determine Immediate Jeopardy related to neglect and failure to prevent elopement. Interviews with clinical providers further underscored the resident’s known risks. The nurse practitioner and physician described the resident as having advanced dementia, confusion, cognitive dysfunction, impulsivity, restlessness, difficulty with redirection, shuffling gait, and muscle weakness, with a history of expressing a desire to go home and requiring assistance with ambulation using a walker. Staff nurses and CNAs reported that the resident frequently wandered, was extremely confused, constantly tried to get up, was unsteady on his feet, and required frequent redirection, with some staff stating he should have been on 1:1 supervision or 15-minute checks due to his behaviors and fall risk. Despite these known risks and the existing care plan identifying elopement risk, staff did not implement effective supervision or appropriate responses to the door alarm on the night of the incident, resulting in the resident’s unwitnessed elopement and injury.

Removal Plan

• Implemented 1:1 supervision with staff at all times for Resident #2 due to elopement risk.
• Implemented an order that Resident #2 may only go out on leave of absence (LOA) with a responsible party.
• Updated Resident #2 care plan to include family assisting with placement to a secured unit.
• Updated Resident #2 care plan to include providing the resident with a 1:1 companion as needed to decrease risk of exit seeking.
• Provided education to the assigned nursing supervisor and assigned nurse regarding responding to alarming doors, searching immediate surroundings, completing a head count when doors alarm, and timely DON notification of elopement.
• Suspended the nurse supervisor and assigned CNA pending investigation.
• Held an ad hoc QA meeting regarding elopement with the Administrator, DON, ADON, VP of Clinical Operations, and Medical Director.
• Conducted ongoing QAPI discussions focused on response to alarming doors, elopement drills, head counts, and prevention of neglect related to elopement.
• Provided education to the DON, ADON, and Administrator regarding the elopement, affected policies, alarming doors, head counts, risk management reports, reporting to AHCA, elopement drills/audits, QAPI, hourly head count, investigation guidance, and ongoing education/monitoring.
• In-serviced department heads on responding to alarming doors and checking surrounding areas to visually ensure the area is secure.
• Initiated abuse and neglect policy education with all current staff, emphasizing neglect, maintaining a safe environment, and required actions when a door alarm sounds.
• In-serviced assigned staff on responding to alarming doors, checking surrounding areas, performing a head count, and neglect/elopement prevention and response.
• Conducted elopement drills on every shift, then implemented random weekly drills performed by DON/ADON/designee.
• Started elopement education audits, then transitioned to random-shift audits performed by DON/ADON/designee.
• Completed elopement risk reassessments for all residents by ADON, clinical unit managers, and DON.
• Reviewed care plans for residents at risk for elopement by DON.
• Reviewed the elopement binder for accuracy by DON.
• Audited all current residents' LOA orders in the electronic health system by DON, ADON, and unit managers.
• Performed routine door monitor/alarm function checks at all exit doors by the Director of Maintenance.
• Tested exit alarms by a third-party independent contractor.
• Updated the CE-4 Elopement Prevention Policy; reviewed with the IDT in ad hoc QAPI and re-issued to all departments with education provisions.
• In-serviced current staff on the updated CE-4 Elopement Prevention Policy.
• Implemented emergency in-servicing education that all alarming doors must be treated as potential resident elopement and require a head count, and that only maintenance can identify a malfunctioning door alarm.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to respond to two exit door alarms and provide adequate supervision to prevent a severely cognitively impaired, high fall- and elopement-risk resident from exiting the building. The resident had dementia with psychotic features and delusions, severe cognitive impairment with a BIMS score of 6, impaired decision-making, a documented determination of incapacitation, and multiple diagnoses including myasthenia gravis, atrial fibrillation on anticoagulation, depression, delusional disorder, and muscle weakness. Care plans and assessments identified the resident as at high risk for falls and at risk for elopement and wandering, with documented wandering, impulsivity, agitation, difficulty with redirection, and unsteadiness on his feet. Therapy notes showed he required supervision or touching assistance and contact guard assist for transfers and gait due to poor safety awareness and high fall risk. On the night of the incident, the resident was last seen around 2:30 a.m. in bed asleep by his assigned CNA. Shortly thereafter, an emergency stairwell exit door alarm by the therapy department on the second floor sounded. The supervisor LPN, who was on the second floor at the time but assigned to the first floor, went to the wrong door near the wound care nurse’s office, attempted to silence the alarm but could not recall the code, and assumed the alarm was malfunctioning. She contacted maintenance rather than initiating the facility’s elopement policy, which required calling a code purple, conducting an immediate search, checking outside, and completing a head count. Another LPN on the unit heard the alarm but was told by the supervisor that it was malfunctioning, and she did not initiate elopement procedures at that time. The assigned CNA was on break when the alarm sounded, received a call from the supervisor asking how to turn off the alarm, believed it was another malfunctioning door based on a similar prior event, and did not check on his residents when he returned from break, even though the alarm was still sounding. Video footage reviewed by the Director of Plant Operations showed the resident walking down the therapy hallway without a walker or wheelchair, holding onto the railing, leaning on the exit door, triggering the alarm at approximately 2:32 a.m., and then exiting through the stairwell. The resident proceeded down two flights of stairs to a first-floor exit door at the back of the facility, where a second alarm (a red screamer) sounded and later self-terminated after 10–15 minutes. Staff on the first floor reported they did not hear or see anything, and no staff were observed responding to the alarms on the video. The resident then walked approximately 170 yards through the back parking lot, crossed a four-lane road with a 40 mph speed limit, and entered a nearby neighborhood in rainy conditions. Local law enforcement was dispatched around 4:48 a.m. to a neighborhood residence for an elderly male with a head injury knocking on doors; officers identified him as the resident from the memory care unit. He was found soaking wet, shivering, and with a laceration to his left eyebrow and a skin tear to his left elbow from a fall, and EMS transported him to the hospital. EMS documentation indicated the fall occurred about two hours before assessment, and the resident had been missing from the facility for approximately two hours without staff knowledge. The facility’s failure to respond appropriately to the exit door alarms and to supervise the resident in accordance with his known fall and elopement risks resulted in his unwitnessed exit and subsequent injury, and surveyors determined this constituted Immediate Jeopardy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure nursing staff were knowledgeable and competent to respond appropriately to exit door alarms, resulting in an elopement. A resident with dementia and severe cognitive impairment, admitted with diagnoses including dementia with psychotic disturbance, depression, delusional disorder, falls, muscle weakness, lack of coordination, and hallucinations, had documented elopement risk. Elopement risk assessments showed scores at or above the facility’s threshold for exit-seeking and wandering, and progress notes described the resident as confused, disoriented, impulsive, wandering, agitated, and difficult to redirect. Therapy and provider documentation indicated the resident had a shuffling gait, muscle weakness, unsteadiness on feet, and required assistance and a walker for safe ambulation. Staff, including the MD and NP, described the resident as having advanced dementia, high risk for elopement and falls, and appropriate for a memory care setting. On the night of the incident, the resident was last seen in bed asleep around 2:30 a.m. by the assigned CNA. Shortly thereafter, the resident exited his room, walked down the hallway past the elevator and nurse’s station, and pushed on an alarmed stairwell exit door near the therapy gym. Video reviewed by the Director of Plant Operations showed the resident walking down the therapy hallway holding the handrail, leaning on the exit door, triggering the alarm, and then exiting through the door after the 15‑second delay while the alarm and audible message sounded. The resident then descended two flights of stairs and exited through another alarmed door on the first floor to the outside of the building. The alarms on both the second-floor and first-floor doors were described by multiple staff and maintenance as loud and audible in the nearby nurse’s station areas, with flashing lights indicating which door was alarming. Despite the alarms sounding, nursing staff did not initiate the facility’s elopement protocol. The supervising LPN on duty went to the wrong exit door, attempted to silence the alarm but could not recall the code, and assumed the alarm was malfunctioning. She contacted maintenance and communicated to other staff that the alarm was a malfunction, leading staff, including the assigned CNA and another RN, to believe it was not a true elopement event. No immediate head count, search of the building, or outside check was initiated at the time the alarm sounded. The assigned CNA was on break when the alarm activated, did not verify the resident’s presence upon returning, and recalled that the alarm continued to sound but did not prompt him to check his residents because he believed it was another malfunction similar to a prior event. Another LPN on the unit heard an unfamiliar alarm sound for a few minutes but did not recognize it as an exit alarm, did not know where it originated, and reported she had never completed elopement drills and was not familiar with the alarm sound. Maintenance staff arrived approximately 15–20 minutes after the initial alarm, found only the therapy hall stairwell door alarming, and successfully reset it, confirming there was no malfunction. First-floor staff reported not hearing the alarm unless they were near the specific door and did not become aware of the situation until law enforcement arrived. Law enforcement records indicated that the supervising LPN acknowledged receiving an open door alarm around 3:00 a.m. but “thought nothing of it, almost ignoring it,” and that no one was covering the watch role while a staff member was on break. The resident was found off premises by local police in a nearby neighborhood, wet from rain, shivering, and with a laceration above the left eyebrow and a skin tear on the left elbow after a fall. EMS documentation and emergency room records confirmed the resident had been missing from the facility for approximately two hours before being located and transported to the hospital for evaluation and treatment. The surveyors determined that staff’s failure to recognize and respond appropriately to the exit door alarms and to follow elopement procedures constituted a lack of competency in providing care and services to prevent elopement for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that four nursing aides, identified as Staff A, B, C, and D, obtained their certified nursing assistant (CNA) certification within four months of their hire dates, as required by Florida regulations. Staff A was hired on June 18, 2024, Staff B and C on September 24, 2024, and Staff D on October 22, 2024. Despite being employed for over four months, none of these staff members had obtained their CNA certification. This deficiency was identified during a review of documentation provided by the Human Resources Director, which confirmed the lack of certification for these staff members. Interviews conducted with the Human Resources Director, the Director of Nurses (DON), and the Nursing Home Administrator (NHA) revealed a lack of awareness and oversight regarding the certification status of these nursing aides. The Human Resources Director confirmed the employment of uncertified nursing aides, while the DON was unaware of their certification status. The NHA acknowledged the requirement for nursing aides to obtain certification within four months of hire but was not aware that Staff A, B, C, and D were working beyond this period without certification. The facility's failure to comply with the certification requirement for nursing aides was a clear violation of the Florida Statutes governing nursing homes and related health care facilities.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately identify and document resident-specific triggers related to PTSD for two residents, leading to a deficiency in providing trauma-informed care. Resident #32, who has a history of PTSD, bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, was observed to be tearful and anxious, particularly in the mornings. Despite receiving psychiatric and psychological services, there was no documentation in her records identifying her PTSD triggers or strategies to prevent re-traumatization. Interviews with staff revealed a lack of awareness and understanding of her specific triggers, and the care plan did not include individualized interventions to address her PTSD. Similarly, Resident #56, who was diagnosed with chronic PTSD, major depressive disorder, mood disorder, and dementia, also lacked a comprehensive care plan addressing her PTSD. Although her records indicated a history of trauma, including being raped at 15, there was no documentation of her triggers or interventions to prevent re-traumatization. Interviews with staff, including the DON and LPN, showed a lack of awareness of her PTSD diagnosis and triggers, and her care plan did not reflect any specific strategies to address her condition. The facility's Trauma Informed Care policy emphasizes the importance of identifying triggers and providing individualized care to prevent re-traumatization. However, the facility did not adhere to these guidelines, as evidenced by the lack of documented triggers and individualized care plans for both residents. This deficiency highlights a failure to provide culturally competent, trauma-informed care as required by professional standards and the facility's own policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were stored securely and were inaccessible to unauthorized individuals, including staff, residents, and visitors. During a facility tour, it was observed that several residents had medications unsecured at their bedsides. Resident #24 had eye drops on the bedside table, which were not included in the self-administration orders, and the resident admitted to not keeping them in the lockable drawer as required. Similarly, Resident #111 had an inhaler/decongestant at the bedside without any physician orders for self-administration. Resident #58 had a medicated powder on a chair by the bedside, also without current orders for self-administration. Interviews with staff confirmed that all medications should be secured, and self-administration orders should be in place for residents to keep medications at their bedside. Additionally, Resident #34 was found to have an inhaler taped to the bed siderails, despite having self-administration orders. The facility's policy requires medications to be stored securely, even for residents with self-administration orders. The Director of Nursing and Assistant Director of Nursing acknowledged that medications should be secured at the bedside. The facility's policy on medication administration and storage emphasizes the need for secure storage and proper authorization for self-administration, which was not adhered to in these cases. Furthermore, a medication cart was left unlocked and unattended by Staff S, an LPN, outside the nurse's station, with resident information visible to others. This was a breach of the facility's policy, which mandates that medication carts and computers be locked when not in use and only accessible to authorized personnel. The facility's policies on medication storage and self-administration were not followed, leading to unsecured medications and potential access by unauthorized individuals.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a dignified dining experience for three residents during a survey. Resident #6 was observed in her room unable to access her lunch tray because her wheelchair was locked, and she required assistance to position herself and open meal containers. Despite having a care plan indicating the need for meal setup assistance, staff did not provide the necessary help in a timely manner, leaving the resident unable to eat independently. Resident #25 was found in bed with his meal tray at his bedside, waiting for assistance for approximately 45 minutes. The resident, who has a history of dementia and hemiplegia, was dependent on staff for meal assistance as per his care plan. Staff acknowledged the delay in providing assistance, which was contrary to the facility's procedure of preparing residents for meals and ensuring timely assistance. Resident #33 was also observed waiting for meal assistance while other residents had finished their meals. The resident, who has cognitive impairments and requires total assistance for eating, was left unattended for about 45 minutes. Staff interviews revealed a lack of coordination and communication among CNAs, resulting in the resident not receiving the necessary help. The facility's policy on dignity and respect was not adhered to, as residents were not treated with the expected level of care and assistance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the confidentiality of residents' personal and medical records, as evidenced by two specific incidents. In the first incident, a metered dose inhaler box with a resident's chart sticker was found in the medication cart trash, which was located in a common hallway visible to non-staff individuals. Interviews with staff revealed that protected health information (PHI) should be shredded before disposal, but this procedure was not followed in this case. In the second incident, two separate observations were made where medication cart computer screens were left unlocked and unattended, displaying residents' information to passersby. In both cases, the responsible LPNs acknowledged their failure to lock the computers and medication carts. The facility's policy mandates the protection and safeguarding of all medical records, but these incidents demonstrate a lapse in adherence to this policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete the Preadmission Screening and Resident Reviews (PASARRs) for residents with mental disorders and intellectual disabilities following qualifying mental health diagnoses. This deficiency was identified for five out of nine residents reviewed. For Resident #43, the PASARR dated 09/29/23 did not have the qualifying diagnoses checked, and recommendations for a Level II PASARR were not acted upon. Similarly, Resident #18's PASARR dated 04/29/24 also lacked the necessary checks and follow-up actions. Resident #24's PASARR from 08/26/19 showed the same oversight, with no action taken on the recommendations for a Level II PASARR. Interviews with the Regional Nurse Consultant (RNC) and Director of Nursing (DON) revealed that the facility had initiated revising the PASARRs but lacked evidence of completion, and they did not have a PASARR policy in place. Resident #31 was admitted with diagnoses including psychotic disorder and bipolar disorder, but the PASARR dated 5/6/24 did not require a Level II assessment despite the presence of qualifying mental health diagnoses. The DON confirmed that the resident did not have a diagnosis of anxiety, which was incorrectly noted on the PASARR. Resident #56's PASARR dated 7/14/22 recommended a Level II assessment due to depressive disorder, but a subsequent PASARR dated 7/27/23 did not reflect any mental illness diagnoses, and no Level II assessment was completed. The DON confirmed the inaccuracies in Resident #56's PASARR and the lack of a Level II assessment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper monitoring and maintenance of negative wound pressure therapy for a resident with necrotizing fasciitis and Fournier gangrene. The resident's negative pressure wound machine was observed not functioning, with tubing hanging on the floor, and the resident reported that the machine caused pain and frequently detached. Despite having orders for negative pressure wound therapy dressing changes and specific settings, the orders were not properly documented in the resident's medical record. The Director of Nursing confirmed the lack of documentation, and staff had difficulty contacting the resident's wound care doctor. Additionally, the facility did not ensure that an upper extremity elevation support wedge was ordered and monitored for a resident with left arm paralysis due to a motor vehicle accident. The resident was observed with his arm not properly positioned on the support wedge, and there were no directions for the nursing staff regarding the application of positioning devices. The resident's care plan did not include any focus, goal, or interventions related to positioning devices, and the therapy department had not evaluated the resident since a hospitalization in 2023. Interviews with staff revealed that the facility's policy required PT and OT to evaluate residents for positioning devices, but the resident's girlfriend had brought the support device to the facility, and CNAs continued to use it without formal orders. The facility's policy on consultants and care planning emphasized the need for proper documentation and physician orders for any recommendations, which were not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that splints were applied to prevent the decrease of range of motion for two residents. Resident #50, who has a history of hemiplegia following a stroke, was observed multiple times without splints or rolls in her hands, despite having physician orders for a right palm roll or washcloth roll every shift. The resident expressed that staff did not frequently apply the splints, and she often forgot to request them. The care plan indicated the need for a towel roll in the right hand for skin integrity, but observations showed that this was not consistently implemented. Resident #88, also diagnosed with hemiplegia following a stroke, was similarly affected. The resident's care plan included a right resting hand splint to be worn from morning to evening or as tolerated every shift. However, interviews with staff revealed confusion about the responsibility for applying the splints, with CNAs and restorative staff each believing it was the other's duty. This lack of clarity resulted in the resident not consistently receiving the necessary splinting care. Interviews with various staff members, including CNAs, LPNs, and the Director of Nursing, highlighted a disconnect between the facility's policy and the actual practice regarding splint application. The facility's policy stated that nursing staff were responsible for applying splints based on a schedule established after assessment, but this was not adhered to. The Director of Rehabilitation confirmed that therapy screened residents quarterly for contracture management, but the responsibility for daily splint application was not clearly communicated or executed, leading to the observed deficiencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper storage and maintenance of respiratory equipment for residents on one of its floors. Observations revealed that a resident's nebulizer mask was left exposed on a nightstand without proper labeling or dating of the tubing, contrary to physician orders requiring weekly changes and labeling. Another resident's CPAP mask was found detached and with its hose on the floor, while a third resident's nebulizer mask was improperly stored in a drawer without a bag. Interviews with staff confirmed that the equipment should be cleaned, stored in a dated bag, and not left on the floor or improperly stored. Additionally, the facility did not provide tracheostomy care and suctioning according to standards for a resident with a tracheostomy tube. The resident was observed with a tracheostomy tube without visible ties and gauze surrounding it. The resident reported being able to self-suction, but there was no documentation of education on suctioning in the medical record. The resident's orders were incomplete, lacking specifics on trach size and self-suctioning, and the oxygen was set at a different rate than ordered. Interviews with staff, including the Director of Nursing, acknowledged the incomplete orders and lack of documentation. The facility's policies on respiratory equipment and tracheostomy care were not adhered to, as evidenced by the improper storage of equipment and incomplete tracheostomy orders. The facility's policy required nebulizer equipment to be stored in a bag and tracheostomy care to be performed at least twice daily, with specific orders for care and treatment. The failure to follow these policies and physician orders contributed to the deficiencies observed during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure complete documentation of narcotic removal, which is crucial for identifying loss or potential diversion of controlled medications. During a medication administration observation, an LPN removed and administered a Norco tablet to a resident but did not document the removal in the medication monitoring control record before proceeding to administer medications to another resident. This lapse in documentation was identified when a review of the resident's Medication Monitoring Control Record showed missing information, specifically the name of the person administering the medication. The Director of Nursing confirmed that the facility's expectation is for staff to document the removal of narcotics in the control record at the time of administration. The facility's policy on medication administration, last reviewed in September 2022, mandates that licensed personnel must document the administration of narcotics in both the Medication Administration Record and the narcotic control substance sheet at the time of administration. The LPN acknowledged forgetting to sign their name, which contributed to the incomplete documentation.